United
Kingdom — A study of boys who were surgically
turned into girls after a rare birth defect has reopened
the nature versus nurture debate about our sexual
identity
WHEN we are born
incomplete, we trust medicine to restore our identity.
And so, over the past few decades, many boys born without
a penis were converted surgically into females soon after
birth - their diminished phalluses removed and
reconstructed as vaginas; their parents encouraged to
raise them as girls.
It was seen as the right
thing to do in a world that could not countenance men
without manhoods, and in a social climate that believed
gender was gifted to us mainly by our
upbringing.
The benevolent intentions
of the past, however, have now turned into one of today's
most heartbreaking and complex medical dilemmas. A highly
controversial American study of men born with cloacal
exstrophy (CE) <http://en.wikipedia.org/wiki/Cloacal_exstrophy>,
a rare, severe condition whose symptoms include phallic
atresia (no penis), suggests that many of these 'women'
grow up to shun their adopted gender.
Of the study's 16 genetic
males (which means they possessed an XY chromosome pair),
14 had been reassigned as female - surgically, socially
and legally. The parents of the remaining two had refused
to permit reassignment (these two patients declared
themselves to be male). Of the 14 'converts', all had
typically male hobbies and behaviours and only five truly
felt female. Only one ever played with dolls.
Eight felt they were male
- four before being told of their condition and four
afterwards. All eight are attracted to women and now want
penises; four of them are actually pursuing penile
reconstruction. The remaining one of the 14 refused to
discuss gender at all. The study, which appears in this
month's New England Journal of Medicine
<http://content.nejm.org/>,
has tremendous implications for the nature versus nurture
debate: if boys raised to look and think as girls still
view themselves as male, then the argument seems to sway
heavily in favour of nature when it comes to sexual
identity. Nurture cannot easily subvert nature, it seems,
even when it is assisted by major surgery.
"We are
challenging the conventional wisdom and urging doctors
not to perform conversion surgery as routine," said Dr
John Gearhart, director of paediatric urology at Johns
Hopkins Children's Centre and co-author of the
study.
"Rather, we suggest
that they strongly consider counselling families to
raise the children as males, and recommend penile
reconstruction at a later age.
"Our findings suggest
that children who are born genetically and hormonally
male may identify themselves as male despite being
raised as females and undergoing feminising
genitoplasty at birth."
However, Dr Polly
Carmichael, a psychologist at Great Ormond Street
Hospital, said that the hospital's own study of CE
patients who had been surgically altered to become female
was much more favourable. "(Gearhart) is saying that
these reassigned females are spontaneously saying they
are male, but our cohort of ten patients do not have that
experience," she says.
The American study
involved only 16 patients, and she says that participants
might have presented themselves at clinic because they
had gender problems which, in other words, possibly meant
they were a self-selecting sample at the problematic end
of the spectrum.
"The difficulty is that
this is a very polarised argument about nature versus
nurture. But we need to know that the evidence is very
good before we move to a blanket policy of not
reassigning gender."
Gearhart's paper,
co-authored by William Reiner of Oklahoma University
<http://www.ou.edu/>,
could have ramifications in intersex conditions, which
are situations where the gender of the child is unclear.
In the past, the medical belief first put forward
by John Money <http://en.wikipedia.org/wiki/John_Money>
in the 1950s was that nurture determined gender
and any corrective surgery should be done quickly after
birth.
This crucial time was a
window in which gender could be fixed, which would allow
better parental bonding. On the basis that it is easier
to hollow out a vagina than construct a functioning
penis, the trend in the 1960s and 1970s was towards
feminising surgery. And, of course, the child was never
told the truth.
But now, as those
children reach adulthood, the backlash has begun. They
are angry at the culture of secrecy and shame, and that
something as personal as gender and genitalia was decided
without their permission. They talk of having their
genitals 'butchered' and, where there is nerve damage,
being deprived of sexual fulfilment.
At a conference on
intersex held in London last week, one of the most moving
presentations was given by Melissa Cull, a 35-year-old
woman with congenital adrenal hyperplasia
<http://en.wikipedia.org/wiki/Congenital_adrenal_hyperplasia>,
a condition that left her with enlarged female genitals.
During childhood, she underwent a number of operations
that left her physically and emotionally scarred and
unable to have a satisfactory physical relationship (she
had to take painkillers before sex). She spoke of doctors
warning her not to touch herself, and of a 'total loss of
ownership of her body'. She finished by asking the
clinicians to imagine having their own genitalia
interfered with: "Would you really put the way you look
before your sexual pleasure, wellbeing and your gender
just to please society?" The 'sex' question has recently
been addressed by Sarah Creighton, consultant
gynaecologist at University College Hospitals
<http://www.uclh.nhs.uk/>
in London, who runs a clinic for intersex adults.
Creighton and her colleague, Dr Catherine Minto, found
that a quarter of the women who underwent clitoral
surgery were unable to achieve orgasm. While every case
is different, Creighton and Minto advocate waiting until
the child is older before surgery, partly because
revision surgery is often needed at puberty.
That view is opposed by
other surgeons. Philip Ransley, consultant paediatric
urologist at Great Ormond Street <http://www.ich.ucl.ac.uk/>,
says that operating later can bring psychological
problems of its own, because untreated children can be
left questioning their gender. "What happens if a girl
has a big penis in the gym?," Ransley asks. "These are
the problems they tell us about. The idea that we just
sit back and wait for the child to decide seems to me a
very poor philosophy."
Creighton, who organised
the London conference, says she has noticed a shift in
parental attitudes towards later surgery, and parents
today are far more ready to accept slight abnormalities.
Creighton says: "It is a really hard choice for parents
to make. Parents worry about things such as the nanny or
childcarer seeing their child naked, and then everybody
knowing. And it is little things, such as going to ballet
or going swimming, that become difficult. I have to say,
many parents are still opting for surgery, although I
think there is a trend towards less surgery for the less
virilised girls. My view is that surgery on babies could
be delayed until their teens, so the child can
participate." Interestingly, Creighton believes the
growing reluctance to opt for early surgery stems from
parents wanting their child to be involved. The current
onus on medical disclosure also makes it virtually
impossible - as well as unethical - to conceal such
secrets if surgery is done.
Honesty, says Jasmine, a
woman born completely female except for the fact that her
reproductive organs were male, is the most important
contribution a parent can make. Jasmine discovered her
condition as a teenager when she failed to start her
periods. She also supports later surgery where possible,
and believes genital reconstruction for purely cosmetic
reasons is rarely justifiable because of the psychosexual
damage that can be done. She says: "I have never come
across a single person who regretted being told the truth
about their past.
"It is important that
children don't think it is a secret kept from them by
their parents. The best advice for parents is not to rush
into a decision about surgery, and not to allow an
operation before they have taken their child
home."
